Healthcare Provider Details

I. General information

NPI: 1477342962
Provider Name (Legal Business Name): LEGEND TREATMENT CENTER OF CLEVELAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14445 BROADWAY AVE
CLEVELAND OH
44125-1957
US

IV. Provider business mailing address

95 MAIN AVE STE 121
CLIFTON NJ
07014-1757
US

V. Phone/Fax

Practice location:
  • Phone: 216-677-8177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA KOENIG
Title or Position: COO
Credential:
Phone: 216-677-8177